ABSTRACT In Europe, a considerable proportion of children and adolescents is affected by depressive symptoms, impairing their everyday life and social functioning.
The aim of this paper is to provide an overview of the depressive symptoms in children and adolescents in Germany, addressing risk factors, comorbidity, and impact of depressive symptoms on everyday life.
In the BELLA study, the mental health module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a representative sample of young people aged 7-17 years was enrolled. Depressiveness, assessed by the CES-DC, as well as other mental health problems were examined in the context of risk and protective factors.
Depressive symptoms showed high prevalence in parent- and self-reports. Higher depression scores were found in those with a high number of psychosocial risks existing in the family, and they decreased as the number of protective factors the children and adolescents had at their disposal increased. Although only half of the boys and girls with high depression scores were regarded as significantly impaired, all of them had a much higher risk for additional mental health problems. Furthermore, their health-related quality of life was limited compared to their peers who had low depression scores.
To differentiate between clinically significant depression and milder forms, it is necessary to take into account the different perspectives of children and their parents. Prevention and intervention should acknowledge the widespread distribution of depressive symptoms in children and adolescents, the high comorbidity of depressive and other mental health problems and the impact of depression on the aspects of everyday life.

[Show abstract][Hide abstract]ABSTRACT:
Research in adults has identified an association between bipolar disorder and suicidal behavior. This relationship, however, has been insufficiently investigated in adolescents to date.
1,117 adolescents from 13 German schools (mean age = 14.83, SD = .63; 52.7% females) completed an extended German version of the Center for Epidemiological Studies Depression Scale (CES-D), which assesses depressive and manic symptoms during the last week, as well as the Self-Harm Behavior Questionnaire (SHBQ) for the assessment of lifetime suicidal behavior.
In the present sample 39.4% of the girls and 23.1% of the boys reported lifetime suicidal thoughts and 7.1% of the girls as well as 3.9% of the boys a lifetime history of suicide attempts. 18.7% of the adolescent sample revealed elevated symptoms of depression and 9% elevated levels of mania symptoms. Elevated sum scores of depression and mania were associated with a higher number of suicidal ideations and suicide attempts. A block-wise regression analysis revealed that sum scores of depression and mania predicted suicidal ideations best. Concerning suicide attempts, the best predictors were age as well as depression and mania sum scores.
Suicidal behavior was reported more often when adolescents demonstrate symptoms of mania as well as symptoms of depression than when they demonstrate only depressive symptoms. The presence of bipolar symptoms in adolescents should alert clinicians to the heightened possibility of suicidal behavior.

[Show abstract][Hide abstract]ABSTRACT:
The prevalence of major depression in adolescents is remarkable. Stress has been hypothesised to contribute to the maintenance of depression in young patients. This study aims to elucidate stress-related predictive variables for the maintenance of depression in young girls. A longitudinal design with a time interval of six months was used to assess stress load and depression in 135 15-year-old girls. Stress was measured by the "Fragebogen zur Erhebung von Stress und Stressbewältigung im Kindes- und Jugendalter" and the cortisol awakening response as a biological indicator for hyperactivity of the HPA axis. Depression was quantified by the "Depressionsinventar für Kinder und Jugendliche". The data were analysed by multiple linear regression. When adjusting for initial depression, psychological stress load, physical stress symptoms, and stress vulnerability proved to be predictive for depression, whereas chronic stress neither at the psychological level nor as indicated by the cortisol awakening response had statistically significant effects. The results show the stability of depression in adolescent girls, but also prove an additional influence of acute stress variables.

[Show abstract][Hide abstract]ABSTRACT:
Social phobia and depression are common and highly comorbid disorders in adolescence. There is a lack of studies on possible psychosocial shared risk factors for these disorders. The current study examined if low social support is a shared risk factor for both disorders among adolescent girls and boys. This study is a part of the Adolescent Mental Health Cohort Study's two-year follow-up. We studied cross-sectional and longitudinal associations of perceived social support with social phobia, depression, and comorbid social phobia and depression among girls and boys. The study sample consisted of 2070 15-year-old adolescents at baseline. Depression was measured by the 13-item Beck Depression Inventory, social phobia by the Social Phobia Inventory (SPIN), and perceived social support by the Perceived Social Support Scale-Revised (PSSS-R). Girls reported higher scores on the PSSS-R than boys in total scores and in friend and significant other subscales. Cross-sectional PSSS-R scores were lower among adolescents with social phobia, depression, and comorbid disorder than among those without these disorders. Low PSSS-R total score and significant other subscale were risk factors for depression among both genders, and low support from friends among girls only. Low perceived social support from any source was not a risk factor for social phobia or comorbid social phobia and depression. As conclusion of the study, low perceived social support was a risk factor for depression, but not a shared risk factor for depression and social phobia. Interventions enhancing perceived social support should be an important issue in treatment of depression.

Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed.
The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual
current impact factor.
Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence
agreement may be applicable.

Page 1

Dr.Susanne Bettge, MPHNora WilleClaus BarkmannMichael Schulte-MarkwortUlrike Ravens-Siebererand the BELLA study groupDepressive symptoms of children andadolescents in a German representativesample: results of the BELLA studyMembers of the BELLA study group: UlrikeRavens-Sieberer (Principal Investigator),Claus Barkmann, Susanne Bettge, MonikaBullinger, Manfred Do ¨pfner, MichaelErhart, Beate Herpertz-Dahlmann, HeikeHo ¨lling, Franz Resch, Aribert Rothenber-ger, Michael Schulte-Markwort, NoraWille, Hans-Ulrich Wittchen.Dr. S. Bettge, MPH (&)Senate Dept. for Health, Environmentand Consumer Protection BerlinOranienstr. 10610969 Berlin, GermanyTel.: +49-30/9028-2679Fax: +49-30/9028-2067E-Mail: susanne.bettge@senguv.berlin.deDipl.-Psych. N. Wille, MPHProf. Dr. C. BarkmannProf. Dr. M. Schulte-MarkwortProf. Dr. U. Ravens-SiebererDept. of Psychosomatics in Children andAdolescentsUniversity Clinic Hamburg-EppendorfHamburg, Germanyj Abstract Background InEurope, a considerable proportionof children and adolescents isaffected by depressive symptoms,impairing their everyday life andsocial functioning. Objectives Theaim of this paper is to provide anoverview of the depressive symp-toms in children and adolescentsin Germany, addressing risk fac-tors, comorbidity, and impact ofdepressive symptoms on everydaylife. Methods In the BELLA study,the mental health module of theGerman Health Interview andExamination Survey for Childrenand Adolescents (KiGGS), a rep-resentative sample of young peo-ple aged 7–17 years was enrolled.Depressiveness, assessed by theCES-DC, as well as other mentalhealth problems were examined inthe context of risk and protectivefactors. Results Depressivesymptoms showed high prevalencein parent- and self-reports. Higherdepression scores were found inthose with a high number ofpsychosocial risks existing in thefamily, and they decreased as thenumber of protective factors thechildren and adolescents had attheir disposal increased. Althoughonly half of the boys and girls withhigh depression scores were re-garded as significantly impaired,all of them had a much higher riskfor additional mental healthproblems. Furthermore, theirhealth-related quality of life waslimited compared to their peerswho had low depression scores.Conclusions To differentiate be-tween clinically significantdepression and milder forms, it isnecessary to take into account thedifferent perspectives of childrenand their parents. Prevention andintervention should acknowledgethe widespread distribution ofdepressive symptoms in childrenand adolescents, the high comor-bidity of depressive and othermental health problems and theimpact of depression on theaspects of everyday life.j Key words depressive symp-toms – children and adoles-cents – comorbidity –health-related quality of life –surveyIntroductionDepressive symptoms and disorders are a substantialandincreasingsourceofillness,disability,andsufferingin childhood and adolescence [13, 28]. Diagnostic ap-proaches describe two important disorders in this field:major depression and dysthymic disorder. These arerecurrent unipolar mood disorders which in childhoodare phenomenologically equivalent to adulthood,ORIGINAL CONTRIBUTIONEur Child Adolesc Psychiatry [Suppl 1]17:71–81 (2008) DOI 10.1007/s00787-008-1008-xECAP 1008

Page 2

besides some developmental differences [8]. With a fewexceptions, the DSM-IV [4] diagnoses of majordepression and dysthymia are comparable to the diag-nostic categories of moderate to severe depression anddysthymia in the ICD-10 [38, 44]. According to theDSM-IV, the diagnosis of major depression requires aperiod of depressed mood or irritability for at least twoweeks in addition to further characteristic symptoms.These may occur in cognition (e.g. poor concentration,feelingsofworthlessnessandguilt)and/oremotion(e.g.tearfulness, loss of temper, reduced sense of pleasure orinterest). Vegetative symptoms, such as changes inappetite and weight, insomnia or hypersomnia orchanges in motor behaviour (agitation or slowingdown) may also occur. Dysthymia in children repre-sents a milder mood disorder with chronically de-pressed mood or irritability for at least 12 months.Cognitive or vegetative symptoms also may be present,but with lesser severity of symptoms than observed inmajor depression.While reviews of previous research report averagefrequencies of depressive disorders in children andadolescents of up to 5% [8, 15, 23], the percentage ofmoderate depression is estimated to range up to 15%[11]. Previous research shows that depressive disor-ders are relatively rare in children but become moreprevalent in adolescents [18]. Furthermore, the sexratio changes considerably with age, as while almostno gender difference can be found in children,depression occurs much more frequently in adoles-cent girls than boys [18, 28].Identification of depressive symptoms and disor-ders in childhood and adolescence is important sincedepressive episodes are likely to recur and persistinto adulthood [24, 32, 36]. They also have a con-siderable impact on social functioning and areassociated with an increased risk of suicide [29, 43].Depression has been observed in different cultures[3] over different timeframes by means of differentmeasurements [25].Even though some children and adolescents areseverely affected by depressive symptoms, clinicallyrelevant disorders are not the only disorders ofinterest. Harrington and Clark [21] argue thataccording to the diagnostic manuals, operationaldefinitions for clinicians do not reflect the full epi-demiological reality. To a certain degree, feelingdown, having difficulties getting going or having lowself-esteem, can mark normal developmental transi-tions. Since depressive symptoms are rather commonin childhood and adolescence (only a minority ofadolescents do not report any depressive symptom[21]), it is difficult to draw the line between normaland pathological signs of depression. Mild to mod-erate symptoms of depression are quite common inyoung people [11]. Even if they do not meet thediagnostic criteria for major depression, young pa-tients show impaired functioning nonetheless [28].Since most of depression-related impairment in theadolescent population results from youth with milddepression, a quantitative approach that takes intoaccount the frequencies of different symptoms pro-vides important information [21].Internalising problems such as depressive symp-toms and disorders in children and adolescents oftenremain unidentified because they have less impact onpatients’ social environment (family members, peers,etc.) than hyperactivity or conduct problems [8]. As aconsequence, depressed children and adolescents re-ceive less help or treatment than necessary [30, 35].To better detect depressive symptoms and disorders,it is important to obtain the children’s and adoles-cents’ own perspective on their problems and not onlythat of their parents.This paper investigates the depressive symptoms ofchildren and adolescents in a German representativesample. Research questions focus on which singledepressive symptoms occur in childhood and ado-lescence, how they aggregate to symptom complexesand how frequently depressiveness of clinical rele-vance occurs. This approach accounts for the entirespectrum of depressive symptomatology, from sub-clinical symptoms up to psychiatrically relevant dis-orders. The associations of depressive symptoms withrisk and protective factors are analysed, as thisinformation is regarded as useful for mental healthscreening, prevention and intervention. Additionally,information is given regarding the relationship ofparent- and self-report on depressive symptoms inorder to assess convergent as well as divergent per-spectives of parents and their children. The burdenand impairment associated with depressiveness isexplored in terms of everyday social functioning,comorbid mental health problems and health-relatedquality of life.MethodsThe BELLA study assesses the prevalence and per-sistence of mental health problems in a representativesample of children and adolescents aged 7–17 years inGermany. Depressive symptoms of children andadolescents were measured in the context of othermental health problems, risk and protective factors,and health-related quality of life [34]. The impact ofrisk and protective factors on mental health andhealth-related quality of life is also determined bymeans of follow-up data collections. In this paper,data and results from the first data assessment areevaluated and presented.72European Child & Adolescent Psychiatry, Vol. 17, Supplement 1 (2008)? Steinkopff Verlag 2008

Page 3

j Recruitment and samplingThe BELLA study is the Mental Health Module of theGerman child and adolescent health interview andexamination study KiGGS [26, 27]. The conceptuali-sation, design and procedure of the BELLA study aredescribed in detail elsewhere [34].The participants of the BELLA study were ran-domly recruited from a national representative sam-ple of 17,641 families participating in the GermanHealth Interview and Examination Survey for Chil-dren and Adolescents (KiGGS), conducted by theRobert Koch-Institute. The KiGGS and BELLA sur-veys took place between May 2003 and May 2006 in167 representative cities and communities of Ger-many. The overall response rate was 66.6% (KiGGS).A random selection of 4,199 families from the KiGGSsample with children aged 7–17 were asked to par-ticipate in the BELLA study. Of these eligible families70% agreed to participate and 68% (1,389 girls and1,474 boys) could be surveyed. Of those, 1,142 hadchildren aged 7–10 years, 780 had children aged 11–13 years and 941 had 14–17 years old adolescents. Ineach family, one parent provided responses to astandardised computer assisted telephone interview.Children aged 11 years and older were questioned aswell. In addition, the participants were asked to fill ina mailed paper questionnaire. Sample-data wereweighted to correct for deviation of the sample fromthe age-, gender-, regional- and citizenship-structureof the German population (reference data 31.12.2004).j InstrumentsFor the assessment of depressive symptoms, theCentre of epidemiological studies depression scale forchildren (CES-DC; [40], for details see [5]) was usedin the BELLA telephone interview with parents andadolescents. The 20 symptom ratings of the CES-DCare summed up to a total score ranging from 0 to 60,with higher scores reflecting higher depression. Ascore above 15 indicates the need for further verifi-cation of depression according to the DSM diagnosticsystem (sensitivity = 71%, specificity = 57%) [19].The 20 CES-DC items are assigned to the four sub-scales ‘‘somatic symptoms and retarded activity’’,‘‘depressed affect’’, ‘‘positive affect’’, and ‘‘interper-sonal problems’’.Anxiety was assessed with the parent- and self-re-port version of the screen for child anxiety relateddisorders (SCARED, [9]) in the five-item short ver-sion. Two instruments were used to collect informa-tion about hyperactivity and attention problems:parent- and self-ratings of the Conners’ scale [14] aswell as the parent-report on the questionnaire forhyperactivity (FBB-HKS, [16]). Conduct problemswereassessedvia parent-reportedproblems scales (delinquent and aggressive behav-iour) of the child behavior checklist (CBCL, [1]). Twofurther items from the CBCL and its self-report ver-sion youth self report (YSR, [2]) were used to identifyself-mutilation, suicide attempts and suicide ideation.The adolescents were asked about problematic eatingbehaviour using the SCOFF questionnaire [31]. TheSDQ impact supplement [20] was used to assess theburden associated with the symptoms of mentalhealth problems.Study-specific questions regarding psychosocialrisks for mental health according to Du ¨hrssen andLieberz [17] and following Rutter’s concept of afamily adversity index [37] were also part of theBELLA questionnaires. Risk factors assessed fromparents’ report were low parental education, frequentand severe conflicts in family and partnership, mentaldisorders or chronic diseases of parents, parentalalcohol problems, single parent family, long lastingunemployment, unwanted pregnancy, impaired har-mony in the parent’s family of origin, and lack ofsocial support during the child’s first year of life.Additionally, parental strain due to daily life and so-cial role demands was assessed by a 12-item scale[10]. A cumulative risk index was aggregated, indi-cating how many of the risks were present [41].Standardised scales for protective factors werepartly integrated into the KiGGS questionnaire foradolescents, and additional scales were elements ofthe BELLA self-report questionnaires. Assessment ofprotective factors, as described in detail by Wille et al.[41] (see also [6]), focuses on personal resources(core items for personal resources, self-efficacy, self-concept, self-esteem, optimism), family resources(family cohesion, parental support), and social re-sources (social support, peer competence).Health-related quality of life (HRQoL) was assessedby the self-report form of the KIDSCREEN-52 [33].The KIDSCREEN-52 describes HRQoL in ten differentdomains (physical well-being, psychological well-being, moods and emotions, self-perception, auton-omy, parents, peers, school, bullying, and financialsituation). For each of the domains, scale scores arecomputed by summing up the domain specific itemratings. The scale scores are converted into T-valuesbased on a European norm sample [33]. T-values aredistributed around a mean of 50 with a standarddeviation of 10.externalisingj Statistical analysisAll statistical analyses using SPSS 12 were based onthe weighted sample-data to represent the age-, gen-S. Bettge et al.Depressive symptoms of children and adolescents73

Page 4

der-, regional- and citizenship-structure of the Ger-man population (reference data 31.12.2004). Thenumber of cases reported in the tables and text refersto weighted data and thus might deviate from thenumber of cases reported in the former description ofthe sample. Data regarding depressive symptoms wereanalysed separately for the age groups 7–10 and 11–17 years for parent-ratings and for self-ratings ofadolescents aged 11–17 years.The prevalence of depressive symptoms are de-scribed as the percentages of agreement with eachsingle symptom. The relations of depressive symp-toms with age and sex are given by correlation coef-ficients (r, U). The convergence of parent- and self-rating was explored using the intra-class correlation.Correlations between aggregated CES-DC depressionscores and risk and protective factors, as well asHRQoL scores, were computed. The impact ofdepressive symptoms on children’s and adolescents’daily life and social functioning was derived fromhigh scores in the SDQ impact scale [20]. The pro-portion of depressive children and adolescents withcomorbid mental health problems was computedusing the established cut-offs of the different mea-surements. Odds ratios adjusted for age and sex werecomputed in order to describe the degree to which therisk of additional problems increases in children andadolescents with high depression scores compared totheir peers with depression scores below the cut-off. ttests were conducted to test for limitations of theHRQoL in children and adolescents with highdepression scores.Resultsj SampleA total of 2,863 children and adolescents were en-rolled in the BELLA study and were asked to completethe telephone interview and paper questionnaires forparents of children aged 7–17 years and for adoles-cents aged 11–17 years. Telephone interviews, whichincluded CES-DC questions about depressive symp-toms, were conducted with 2,789 parents and 1,845adolescents. Cases in which parents (2.6%) or 58adolescents (3.0%) failed to complete the telephoneinterview were therefore excluded from all analyses.The main reason parents gave for not completing theinterview were problems with the German language,while the reasons for not interviewing adolescentsincluded withdrawal of their consent or inability tocontact them. The final sample in this paper consistedof 2,860 children and adolescents, for whom at least aparent-report or a self-report of depressive symptomswas obtained.j Prevalence of depressive symptoms and symptomcomplexesTable 1 shows the prevalence of depressive symp-toms in the CES-DC subscales according to the re-sponse categories ‘‘some’’ and ‘‘a lot’’. Results arepresented separately for the parent-report of 7–10and 11–17 year olds and the self-report of the11–17 year old children and adolescents, stratified bygender.All items of the positive affect subscale showedhigh prevalence in the parent-report as well as in theself-report, indicating a lack of positive affect. Apartfrom the positive affect items, the most frequentlyendorsed single symptom in the parent-report was‘‘couldn’t pay attention’’. Together with ‘‘didn’t sleepas well as usual’’, this was also the item most oftenmentioned by girls in the self-report, whereas boysmore often described themselves as ‘‘more quiet thanusual’’ and ‘‘too tired to do things’’.In the parent-report, there were no relevant dif-ferences between boys and girls regarding the fre-quency of depressive symptoms (|U| < 0.10 for allitems). In the self-report, most symptoms were re-ported by a greater proportion of girls than of boys,but the differences—though partly reaching statisticalsignificance—had a low effect size. For the items ‘‘feltlike crying’’, ‘‘felt sad’’, and ‘‘felt like I was as good asother kids’’, the contingency coefficient was U > 0.10,indicating higher symptom scores for girls.All items in the parent-report and most items in theself-report do not vary with age. Exceptions coverthree items in the ‘‘somatic symptoms and retardedactivity’’ domain (i.e. ‘‘felt too tired to do things’’,‘‘didn’t sleep as well as usual’’, and ‘‘it was hard to getstarted’’) and one item from the ‘‘positive affect’’ do-main (i.e. ‘‘had a good time’’), which all were chosenmore often as the age of the adolescents increased(0.10 £ r £ 0.14).In Table 2, the depressive symptoms are aggre-gated to symptom complexes according to the sub-scales of the CES-DC. The table shows the proportionof children and adolescents who answered at least oneitem of the symptom complex with ‘‘some’’ or ‘‘a lot’’(for the symptom complex ‘‘positive affect’’, propor-tions were based on the response categories ‘‘not atall’’ and ‘‘a little’’ in analogy to Table 1). Results arepresented separately for the informants and agegroups, stratified by sex.With regard to the parent ratings, about onequarter of all children and adolescents showeddepressive symptoms in the area of somatic com-plaints or lack of energy during the last week. In theage group 11–17 years, parents more frequently de-scribed their boys as showing a lack of positive affect(U = )0.06). Symptoms indicating depressed affect74 European Child & Adolescent Psychiatry, Vol. 17, Supplement 1 (2008)? Steinkopff Verlag 2008

Page 5

are reported for 11–15% of the boys and girls. A lackof positive affect was reported for more than half ofthe respondents. Interpersonal problems, assessed bytwo items, were only reported by a small subgroup,mainly consisting of children aged 7–10 years.All symptom complexes reached higher prevalencein the self-report than in the parent-report, with thegreatest difference between the two on the ‘‘somaticsymptoms and retarded activity’’ subscale. Symptomsof depressed affect were reported more often by girlsthan boys (U = 0.08). A significant correlation ofdepressivesymptomswithagewasobservedonlyinthe‘‘somatic symptoms and retarded activity’’ complex(r = 0.11), suggesting that more symptoms in this areawerereportedwithanincreasingageoftheadolescents.j Correlates of depressivenessThe inter-individual agreement of parent- and self-re-portondepressivesymptomswaslimited,assuggestedby an intra-class correlation coefficient of 0.34 for allparticipants (data not shown). The intra-class corre-lationofCES-DC sumscoresdid not differbetween theyounger and the older adolescents (11–13 years: 0.33,14–17 years: 0.36) and between boys (0.31) and girls(0.38).CorrelationsofdepressivesymptomscoreswithriskandprotectivefactorsassessedintheBELLAstudy[41] were therefore examined separately for the CES-DC parent- and self-reports.The cumulative risk index was moderately corre-lated with the parental reported depressive symptoms(r = 0.23). In addition, a small correlation with self-reported symptoms (r = 0.12) was observed (data notshown). The depressiveness reported by parents waspositively correlated with parental strain (r = 0.29),meaning that parents reporting a high level of stressand burden due to social demands also rate theirchildren’s depressive symptoms to be more severe.Self-reported depressive symptoms showed a lowercorrelation with parental strain (r = 0.12) (data notshown).Table 1 Prevalence of depressive symptoms (response categories ‘‘some’’ & ‘‘a lot’’, proportions in %)Subscale/ItemParent-report Self-report7–10 years 11–17 years11–17 yearsBoysGirls BoysGirlsBoys GirlsI. Somatic symptoms and retarded activityWas bothered by thingsDid not feel like eatingCouldn¢t pay attentionFelt too tired to do thingsDidn’t sleep as well as usualWas more quiet than usualIt was hard to get startedII. Depressed affectWasn¢t able to feel happyFelt down and unhappyFelt like things didn¢t work out rightFelt scaredFelt lonelyFelt like cryingFelt sadIII. Positive affectFelt like he/she/I was as good as other kids*Felt like something good was going to happen*Was happy*Had a good time*IV. Interpersonal problemsKids were not friendly to him/her/meFelt people didn’t like him/her/me3.34.513.34.96.52.44.95.07.59.24.14.31.36.74.53.511.55.54.63.210.94.23.18.56.25.43.77.07.44.89.710.78.512.04.78.58.211.911.611.98.15.12.64.32.94.33.55.14.11.35.23.42.63.76.55.43.75.43.43.12.02.43.52.65.52.72.22.53.74.65.65.16.02.12.61.54.57.08.98.14.93.55.310.018.653.99.28.421.150.14.56.023.760.915.713.225.557.912.412.030.559.812.18.941.258.114.613.04.52.65.02.82.31.63.21.65.12.12.82.5*Item reversed (i.e., proportions for response categories ‘‘not at all’’ and ‘‘a little’’ are reported)Table 2 Prevalence of depressive symptom complexes (proportions in %)Symptom complex(CES-DC subscale)No. ofitemsParent-reportSelf-report7–10years11–17years11–17yearsBoys Girls Boys Girls Boys GirlsI. Somatic symptomsand retarded activityII. Depressed affectIII. Positive affectIV. Interpersonal problems 2724.423.3 25.2 22.8 33.0 36.87414.560.46.014.0 11.059.0 70.55.612.5 15.465.1 70.73.721.770.94.5 3.3 6.2S. Bettge et al.Depressive symptoms of children and adolescents75

Page 6

We found that depressive symptom scores werenegatively correlated with all protective factor scalesthat wereadministered as self-report instruments inthestudy (Table 3). Moderate correlations were observedbetweenpersonal,familyandsocialresourcesscalesandthe CES-DC self-report. The magnitude of the correla-tions in the three resources areas was similar. Thehighest correlation was found for the self-esteem scaleanswered by the adolescents with their self-reporteddepressiveness. Thecorrelations of the protective factorscales with the depression scores reported by the par-ents were lower than with the CES-DC self-report.j Burden and functional impairment associated withdepressivenessIn the parent-report of the CES-DC, 10.9% of thescores were beyond the cut-off for the clinical rele-vance of 15. This proportion was nearly equal inchildren aged 7–10 years (10.6%) and adolescentsaged 11–17 years (11.1%). As shown in the light-shaded bars in Fig. 1, the 7–10 year old boys are de-scribed by their parents as having depressive prob-lems slightly more often than the girls of this agegroup, while in the 11–17 year old age group, theproportion was reversed. Altogether, gender differ-ences were small and without clinical significanceaccording to the parent-report. In the adolescents’self-report, however, girls reached high depressionscores above the cut-off nearly twice as often as boys.When a high SDQ impact scale score (indicatingmoderatetosevereimpairmentinatleast twodomains)was used as an additional criterion, the prevalence ofchildren (7–10 years) identified as depressive was re-ducedfrom11%to5%forboysandfrom10%to5%forgirls. The reduction was similar in the 11–17 year agegroup (dark-shaded bars in Fig. 1).Approximately one third of the boys with high self-reported depression scores on the CES-DC also hadhigh SDQ impact scores. The proportion of girls withhighCES-DCdepressionscoresthathadalsodescribedthemselves as impaired in everyday functioning on theSDQ impact scale was higher than that of the boys.Table 3 Correlation of depressive symptoms with protective factorsProtective factorCorrelation* with CES-DCParent-report11–17 yearsSelf-report11–17 yearsPersonal resourcesCore items personal resourcesSelf-efficacySelf concept (CHIP)Self-esteem (SPPC)OptimismFamily resourcesFamily cohesionParental supportSocial resourcesSocial supportPeer competence)0.16)0.16)0.16)0.26)0.17)0.30)0.29)0.38)0.43)0.36)0.17)0.14)0.28)0.31)0.15)0.15)0.23)0.33*P < 0.01 for all correlations25%CES-DC above cut-offCES-DC above cut-off & high SDQ impact score11,3%5,3%boysgirls7–10 years 11–17 yearsparent-reportself-report11–17 yearsboysgirls boysgirls9,9%4,6%10,7%5,9%11,5%5,3%12,3%21,2%9,7%4,7%20%15%10%5%0%Fig. 1 Prevalence of depressiveproblems with and without reportedimpairment76European Child & Adolescent Psychiatry, Vol. 17, Supplement 1 (2008)? Steinkopff Verlag 2008

Page 7

j Comorbidity of children and adolescents with highdepression scoresTable 4 presents which proportion of study partici-pants with high depression scores (CES-DC abovecut-off) showed additional specific mental healthproblems. Anxietyproblemscomorbidity for girls than boys in the parent-reportas well as in the self-report, particularly in theyounger age group. The odds ratio (OR) adjusted forage and sex for comorbid anxiety problems in chil-dren and adolescents with high depression scores wasOR = 6.1 (95% CI: 4.6–8.1) for the parent-reportedsymptoms and OR = 5.6 (95% CI: 4.2–7.5) for theself-report.Hyperactivity problems, as assessed by the Con-nors’ scale in parent- and self-reports, were reportedby more than one third of the parents that describedtheir children as having depressive problems. Lessthan one fifth of the adolescents, however, stated thesesymptoms themselves. In addition, the odds ratio forthe parent-report (OR = 8.4, 95% CI: 6.3–11.1) wasconsiderably higher than for the self-report (OR =3.3, 95% CI: 2.2–5.0). The numbers reported forADHS comorbidity of children and adolescents withdepressive problems, assessed only from the parentsin the FBB-HKS, contradicted the high comorbidityrates. In addition to the depressive symptoms, 21% ofthe parents reported marked ADHS problems for theyounger boys aged 7–10 years. In contrast, only 4–8%of the girls and older boys aged 11–17 years werereported as having both problems. The overall oddsratio adjusted for age and sex was OR = 3.6 (95% CI:2.1–6.1).Approximately one third of the parents reportingdepressive problems of their children also describedthem as having externalising problems (see Table 4).For the younger boys, as many as half of the parentsreport both problems. An overall odds ratio of 3.7showeda higher(95% CI: 2.8–5.0) was computed for the comorbidityof depressive and externalising symptoms.The rate of suicidal and self-mutilation comor-bidity of children and adolescents with depressiveproblems varied substantially across the subgroupsconcerned. This rate ranged from 2% to 16% in theparent-report, which was relatively constant over thetwo age groups for girls. The rate, however, jumpedfrom 2% for boys aged 7–10 years to 16% for 11–17 year old boys. In the self-report, a higher propor-tion of girls with depressive problems describedthemselves as also having suicidal and self-mutilationsymptoms compared with the boys, whose rate ofcomorbidity was under their parents’ in this area.Comorbidity odds ratios were higher in the self-report(OR = 7.0, 95% CI: 4.6–10.8) than in the parent-re-port (OR = 5.2, 95% CI: 3.2–8.4).In addition, almost half of the girls with depressiveproblems reported problematic eating behaviours,which was almost twice as much as the comorbidityself-reported by the boys. The age and sex adjustedodds ratio was computed with OR = 2.6 (95% CI:2.0–3.4).j Quality of life of children and adolescents withhigh depression scoresFigure 2 depicts the impact of depressive symptomson the adolescents’ health-related quality of file,measured by the KIDSCREEN-52 questionnaire. Thequality of life scores of the adolescents withoutdepressive problems ranged beyond T-values of 50 inall domains, suggesting that their quality of life wasabove the average of the European norm sample. Incontrast, the quality of life scores of the 248 girls andboys reporting to have depressive problems werebelow the T-value of 50 in nine of the ten domains.Only in the financial subscale, their scale scores reachTable 4 Comorbid problem prevalences (proportion of children/adolescents with high depression scores above cut-off in other instruments in %)Problem (instrument)Parent-reportSelf-report7–10 years 11–17 years 11–17 yearsBoysGirlsBoys GirlsBoys GirlsAnxiety (5-item SCARED)Hyperactivity (Conners’ scale)ADHS (FBB-HKS)aExternalizing problems (CBCL)aSuicidality (CBCL/YSR)bProblematic eating behaviour (SCOFF)c23.634.520.851.01.8–47.839.14.833.36.5–33.736.47.828.615.8–37.338.83.530.96.9–33.911.5––13.826.544.616.6––20.247.9aOnly parent-reportbAt least one of two items (self mutilation/suicidal behaviour or suicide ideation) is answered ‘‘sometimes’’ or ‘‘often/always’’cOnly self-reportS. Bettge et al.Depressive symptoms of children and adolescents77

Page 8

a T-value of 50.1, which still is significantly lower thanthat of their peers without depressive problems. In allquality of life subscales, the difference between par-ticipants with and without depressive problems washighly significant. Figure 2 also shows the effect sizes,which were highest in the ‘‘moods and emotions’’domain followed by ‘‘psychological well-being’’,‘‘bullying’’, and ‘‘self-perception’’. Apart from thesedomains that had high effect sizes and which ap-peared to be the closest related to depressive prob-lems, the effect sizes were of medium size in all otherquality of life domains, with the exception of the‘‘peers’’ domain in which a small effect is found.A similar analysis conducted separately for boysand girls confirmed the data shown in Fig. 2. Overall,boys tended to report a higher quality of life in alldomains, but when affected by depressive problems,theyshowedsimilarimpairmentsinthevariousqualityof life domains as the girls. Remarkable sex differencesemergedinthe‘‘parents’’,‘‘autonomy’’and‘‘financial’’subscales, where girls with depressive problemsshowed clearly stronger impact than boys. Conversely,boys with depressive problems were more impairedthan girls in the ‘‘bullying’’ subscale (data not shown).Correlations of depression scores with the subscalescores for HRQoL were highest for the ‘‘moods &emotions’’ (r = )0.50), ‘‘psychological well-being’’(r = )0.45), and ‘‘self-perception’’ (r = 0.41) domains,andwere between r = )0.26 andr = )0.36fortheotherseven subscales.DiscussionThe results presented here provide insight to chil-dren’s and adolescents’ mental health with specialregard to depressive symptoms. Depressiveness inchildren and adolescents is examined from their ownpoint of view as well as their parents’. Unfortunately,a gold standard for the assessment of depressivedisorders in population-based studies such as theBELLA study is not yet developed [35]. The CES-DCcut-off score [19] was used to identify a group of boysand girls with clinically relevant depressive symp-toms. Although exceeding this score does not imply aclinical diagnosis of depression, this group of childrenand adolescents have a noticeable amount of depres-sive symptoms that in the least requires furtherdiagnostics.Compared to the other CES-DC subscales, the‘‘positive affect’’ items show higher prevalence (seeTable 1). This might be explained by the fact thatthese four items are worded in a reverse fashioncompared with the other 16 items. Besides the posi-tively worded items, the single symptom most oftennamed by parents is ‘‘couldn’t pay attention’’, which60adolescents with low depression scores (n=1312)adolescents with high depression scores (n=248)PhysicalPsychological WellbeingMoods & EmotionsSelf PerceptionAutonomyParentsPeersSchoolBullyingFinancial5550T-values4540KIDSCREEN-52 quality of life domaind = .66d = .89 d = 1.01d = .85 d = .59 d = .69d = .43d = .65 d = .86 d = .54Fig. 2 Health-related quality of lifeof adolescents with high vs. lowdepression scores78 European Child & Adolescent Psychiatry, Vol. 17, Supplement 1 (2008)? Steinkopff Verlag 2008

Page 9

is more a sign of attention deficit problems thandepression. The comparatively high prevalence ratesin single symptoms are reflected in the prevalence ofdepressive symptom complexes (Table 2), raising thequestion of how seriously the symptoms have to betaken.More than every tenth participant of the studyshowed parent-reported scores of depressivenessabove the clinical cut-off with minimal age and sexdifferences (Fig. 1). According to the self-report, theprevalence of clinically relevant depressiveness issomewhat higher than the parent-report for boys butalmost twice as high for girls.When associated impairment is used as an addi-tional criterion for the identification of children andadolescents with depressive problems (Fig. 1, see also[42]), the prevalence is reduced to about half of thoseidentified by the CES-DC. Still, twice as many girlsreported being significantly impaired in everydayfunctioning by their symptoms. This supports theneed for a clinical procedure for reliably identifyingdepression. Questionnaire methods, especially thoseexclusively applying symptom ratings, will always belimited and lead to overestimation [20].Parents judgement and the child/adolescent self-report showed only limited agreement. This appliesnot only to the amount of depressive symptoms re-ported by parents and adolescents, but also to theinter-individual agreement on the depressive symp-toms of each participant. This corresponds to inter-rater concordance for the other mental healthinstruments in this study (data not presented) as wellas to reports from other studies regarding mentalhealth problems or subjective health reports [7, 39].Still, it is remarkable that the girls’ self-report andtheir parents’ report had the tendency to correlatebetter than for boys, although boys and their parentswere more consistent with regard to the level ofdepressive symptoms. A possible explanation couldbe that the adolescent girls communicate with theirparents more than boys regarding emotional topics,but their appraisal of the severity of symptoms differs.The finding that the adolescents report moredepressive symptoms than their parents agrees withother studies [8]. Unfortunately, there is no way todecide whether this disagreement can be explained byparents’ lack of awareness of their children’s (espe-cially girls’) problems, or whether the adolescents aremore sensitive to the perception and description oftheir symptoms, even if they are not severe enough tobe of clinical relevance.In this regard, it is noticeable that parent-reportslack meaningful sex differences. It is possible thatparents compare their child with peers of the samesex and age when answering the questions, thusreducing the differences that could otherwise be ex-pected. For the clinical setting, it should be concludedthat it is extremely important to include both theparents’ and the child’s perspective, especially when adiagnosis in an emotional area is concerned.A relatively high comorbidity of depressive andanxiety symptoms (Table 4) agrees with other studies[15]. The high comorbidity of hyperactivity andexternalising problems with depressive problems inthe parent-report was also reported by Lehmkuhlet al. [28]. One possible explanation is that someparents regard their children as generally ‘‘problem-atic’’, producing high problem scores in all ques-tionnaires applied. In regard to the comorbidity ofsuicidal with depressive problems, it must be takeninto account that the case numbers are relativelysmall. A clear association between suicidal anddepressive symptoms can be seen in the self-andparent-reports for adolescents and younger girls, butnot boys. The much higher proportion of girlsreporting problematic eating behaviour (see also [22])as can be seen here for adolescents with highdepression scores are consistent with the results fromearlier studies [8].Clinical diagnostics have to take into account highcomorbidity and must therefore explore both thesymptoms presented first as well as other potentialmental health problems, such as externalising symp-toms. Suicidal symptoms and problematic eatingbehaviour also play an important role in adolescentswith depressive problems and should be addressed inany treatment of depressed boys and girls [43].In children and adolescents with high depressionscores, the impairment that can be seen in virtuallyevery aspect of health-related quality of life shows thatthe impact of depressive problems is a very generalone. The emotional symptoms and the impaired self-concept typical of depressive problems have negativeconsequences on the children’s and adolescents’family life, their social contacts and their coping withschool demands.Depression was accompanied by other mentalhealth symptoms (see Table 4), by a lack of protectivefactors (see Table 3) and by impairments in all qualityof life domains (see Fig. 2). This demonstrates thatprevention and intervention should address theseareas in addition to the core depressive symptoms.Harrington and Clark [21] point out that most of themorbidity and burden associated with depressivesymptoms arises from children and adolescents whohave no psychiatric diagnosis of depression, but onlymild depressive problems. Prevention should there-fore also aim at these milder forms of depression.Depressive symptoms and depressive problems area frequent phenomenon in childhood and adoles-cence. Children and adolescents with mental healthproblems need to be identified, diagnosed withS. Bettge et al.Depressive symptoms of children and adolescents79